Welcome to our online Patient Intake Form.
The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the Submit button at the bottom of this form.
For your protection and security; Navigating away from this form before clicking the Submit button will dismiss all completed form fields. Successful submission will redirect you to a conformation page.
Patient Information
How did you find out about our office?
Did you hear about our office from an advertisement?
No
Yes
If Yes, Where:
Did you hear about our office from a phone or professional directory?
No
Yes
If Yes, Where:
What is the purpose of your visit?
Wellness
Complaint
Injury
Other
How do you plan to pay for care?
Personal Insurance
Third-Party Insurance
No Insurance, Self-Pay
Where did the injury occur?
Automobile
Work
3rd Party Premises
Unknown
Other
Have you missed any work due to this injury?
No
Yes
If yes:
Have you reduced or limited your work hours because of this condition?
No
Yes
If Yes, Explain:
Have you received professional treatment for this condition?
No
Yes
If Yes, Explain:
Was treatment effective?
No
Yes
Have you ever had this same condition?
No
Yes
Family/Primary Physician
List each condition on a separate line. Separate details with "," comma as shown above.
List each on a separate line.
Are you pregnant, or have you had any signs of pregnancy? (Female Only)
No
Yes
List each medication on a separate line. Separate details with "," comma as shown above.
List each on a separate line. Separate details with "," comma as shown above.
In the last 5 years have you ever:
List each on a separate line. Separate details with "," comma as shown above.
(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)
Social History & Life Choices:
Health Problems & Concerns Currently Experiencing or Have Previously Experienced
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic.
I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I also request payment of government benefits to Chiropractic Plus. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
Consent to Give Treatment to a Minor Child
I hereby authorize Chiropractic Plus and whomever they may designate to administer chiropractic care as neccessary to my minor child.
